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SS UU BB SS II DD II ZZ II N GG HH EE AA LLTT HH CC AA RR EE
Coverage is available for qualified spouses, children
0-18 and college students of working and temporarily
unemployed adults. Children must enroll in
SoonerCare if they qualify. Spouses of members with
disabilities must apply for membership separately
due to income guidelines.
insureoklahoma.org
March 2012
DEPENDENTS
Apply online at
888-365-3742
or Call
to have the forms mailed to you
This publication was printed and issued by the Oklahoma Health Care Authority as authorized
by 65 0.S. 1991, sec. 3-110, and was funded by tobacco tax revenues deposited into the Health
Employee and Economy Improvement Act Revolving fund at a cost of $697.50 for 10,000
copies. Copies have been deposited with the Publications Clearinghouse of the Oklahoma
Department of Libraries.
2401 NW 23rd St. Suite 1-A
Oklahoma City, Oklahoma 73107
Individual
Plan
PREMIUMS
The monthly premium will not exceed 4% of the
monthly GROSS HOUSEHOLD income.
Below are some of the covered services with
co-payment amounts:
CO-PAY
Office Visit:
Pharmacy Generic:
Pharmacy Brand:
Emergency Visit:
(waived if admitted)
Hospital Inpatient Stay:
Hospital Outpatient Services:
All services must be medically necessary and referred by
their Primary Care Provider (PCP). Some services require an
additional prior authorization.
It is the individual’s responsibility to make the
co-payment at the time of service.
Not all health care services are covered. Please see the
member handbook for more information.
COVERED SERVICES AND
CO-PAYMENTS
$10
$5
$10
$30
$50
$25
To see if your child(ren)
may qualify for Insure Oklahoma
please call 888-365-3742 or visit
www.insureoklahoma.org.

SS UU BB SS II DD II ZZ II N GG HH EE AA LLTT HH CC AA RR EE
Coverage is available for qualified spouses, children
0-18 and college students of working and temporarily
unemployed adults. Children must enroll in
SoonerCare if they qualify. Spouses of members with
disabilities must apply for membership separately
due to income guidelines.
insureoklahoma.org
March 2012
DEPENDENTS
Apply online at
888-365-3742
or Call
to have the forms mailed to you
This publication was printed and issued by the Oklahoma Health Care Authority as authorized
by 65 0.S. 1991, sec. 3-110, and was funded by tobacco tax revenues deposited into the Health
Employee and Economy Improvement Act Revolving fund at a cost of $697.50 for 10,000
copies. Copies have been deposited with the Publications Clearinghouse of the Oklahoma
Department of Libraries.
2401 NW 23rd St. Suite 1-A
Oklahoma City, Oklahoma 73107
Individual
Plan
PREMIUMS
The monthly premium will not exceed 4% of the
monthly GROSS HOUSEHOLD income.
Below are some of the covered services with
co-payment amounts:
CO-PAY
Office Visit:
Pharmacy Generic:
Pharmacy Brand:
Emergency Visit:
(waived if admitted)
Hospital Inpatient Stay:
Hospital Outpatient Services:
All services must be medically necessary and referred by
their Primary Care Provider (PCP). Some services require an
additional prior authorization.
It is the individual’s responsibility to make the
co-payment at the time of service.
Not all health care services are covered. Please see the
member handbook for more information.
COVERED SERVICES AND
CO-PAYMENTS
$10
$5
$10
$30
$50
$25
To see if your child(ren)
may qualify for Insure Oklahoma
please call 888-365-3742 or visit
www.insureoklahoma.org.